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�� 1� pggOJP p STATE OF CALIFORNIA e s STATE WATER RESOURCES CONTROL BOARD ip o UNDERGROUND STORAGE TANK PERMIT APPLICATION - FORM A 0 COMPLETE THIS FORM FOR EACH FACILITYISITE MARK ONLY ❑ I NEW PERMIT ❑ 3 RENEWAL PERMIT ❑ 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE ONE ITEM ❑ 2 INTERIM PERMIT ❑ d AMENDED PERMIT ❑ 6 TEMPORARY SITE CLOSURE I. FACILITY/SITE INFORMATION&ADDRESS-(MUST BE COMPLETED) DBA OR FACILITY NAME NAME OF OPERATOR �•1�(SE'T� EjbE�'r '2'�3% ADDRESS NEAREST CROSS STREETPARCELp(OPTIONAL) CITY NAME STATE ZIP CODE SITE PHONE k WITH AREA CODE ' i 0 r-j CA -9715Z40 — ✓ BOR TO INDICATE D CORPORATION Q INDIVIDUAL O PARTNERSHIP E-1 LOCAL-AGENCY Q COUNTY-AGENCY 0 STATE-AGENCY FEDERAL-AGENCY DISTRICTS TYPE OF BUSINESS ❑ 1 GAS STATION ❑ 2 DISTRIBUTOR ❑ ✓ IF INDIAN #OF TANKS AT SITE E.P.A. L D.#(optional) 3 FARM 4 PROCESSOR 5 OTHER RESERVATION I ❑ ❑ OR TRUST LANDS EMERGENCY CONTACT PERSON (PRIMARY) EMERGENCY CONTACT PERSON (SECONDARY)-optional DAYS: NAME(LAST,FIRST) PHONE a WITH AREA CODE DAYS: NAME(LAST,FIRST) NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE#WITH AREA CODE If. PROPERTY OWNER INFORMATION• MUST BE COMPLETED NAMECARE OF ADDRESS INFORMATION a c/764'r -M�sr/- MAILING OR STREET ^ADDRESS ^^ ✓ box bintlkale INDIVIDUAL 0 LOCAL-AGENCY 7]STATE-AGENCY CORPORATION Q PARTNERSHIP E�D COUNTY AGENCY 0 FEDERAL-AGENCY CITY NAME STATE ZIP CODE PHONE#WITH AREA CODE 1,0a G4 4-15?'l0 III. TANK OWNER INFORMATION-(MUST BE COMPLETED) NAMEOFOWNER�j •' CARE OF ADDRESS INFORMATION MAA2IILINGOR/STRREEETADD�TRESS• ✓box 0Indbab INDIVIDUAL = LOCAL-AGENCY Q STATE-AGENCY Jif (i✓M/Y �CORPORATION PARTNERSHIP = COUNTY-AGENCY FEDERAL-AGENCY CITY NAME' STATE ZIP CODE PHONE#WITH AREA CODE Low C4 ---75 0 IV. BOARD OF EQUALIZATION UST STORAGE FEE ACCOUNT NUMBER-Call(916)323-9555 if questions arise. TY(TK) HQ LZ]-L]�-1 V. PETROLEUM UST FINANCIAL RESPONSIBILITY-(MUST BE COMPLETED)—IDENTIFY THE METHOD(S) USED ✓ box to indicate I SELF INSURED 0 2 GUARANTEE O 3 INSURANCE 1 SURETY BOND 0 5 LETTER OF CREDIT 11 6 EXEMPTION E:1 99 OTHER VI. LEGAL NOTIFICATION AND BILLING ADDRESS Legal notification and billing will be sent to the tank owner unless box I or II is checked. CHECK ONE BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR LEGAL NOTIFICATIONS AND BILLING: I.❑ II.❑ III.❑ THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT APPLICANT'S NAME(PRINTED&SIGNATURE) APPLICANTS TITLE DATE MONTHIDAYI'EAR LOCAL AGENCY USE ONLY COUNTY# JURISDICTION# FACILITY# zj'15 - 6�Z/G 7 LOGATIONCODE OPTIONAL I CEENSUSTTRRACT# -OPTIONAL SUPVIgSOR-DISTRICT CODE -OPAONAL L7— .50 `/L D THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE PERMIT APPLICATION• FORM B,UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. FORM A(12-e1) FILE THIS FORM WITH THE LOCAL AGENCY IMPLEMENTING THE UNDERGROUND STORAGE TANK REGULATIONS IF FOBDWGA R6